Ulnar Abutment Syndrome Research Articles

Ulnar Shortening Osteotomy for Ulnar Abutment Syndrome: The Results of Metaphyseal and Diaphyseal Osteotomies.

Background: The purpose of this study was to report the results of metaphyseal and diaphyseal ulnar shortening osteotomies (USO) for the treatment of ulnar abutment syndrome (UAS). Methods: From 2011 to 2016, we performed metaphyseal USO in 8 patients (8 wrists) and diaphyseal USO in 6 patients (7 wrists). The results were investigated in terms of bone union and cast immobilization, wrist and forearm range of motion (ROM). The mean follow-up duration was 29 months. Results: All 14 patients had bone union. The mean duration of bone union in metaphyseal USO and diaphyseal USO were 3.5 months and 4.3 months and the duration of cast immobilization after surgery were 24.2 days and 29.2 days. The mean forearm ROM (degree) were 134.3 (pronation/supination: 66.7/67.6) and 169.3 (pronation/supination: 84.3/85.0) at 3 months after surgery and 173.4 (pronation/supination: 86.0/87.4) and 172.8 (pronation/supination: 87.1/85.7) at 6 months after surgery. Conclusions: The results from this study suggest that metaphyseal osteotomies are an effective alternative to diaphyseal osteotomies for the treatment of ulnar abutment syndrome. Although metaphyseal osteotomies were associated with temporary decrease of pronation, this discrepancy resolved at 6 months postoperatively. Metaphyseal USO has the potential to promote primary bone union and appears to be an alternative treatment for UAS.

Morphology at the Distal Radioulnar Joint: Identifying the Prevalence of Reverse Obliquity.

Background Recent advances in the understanding of ulnar-sided wrist pathologies such as ulnar abutment syndrome (UAS) have brought increased attention to the anatomy of the distal radioulnar joint (DRUJ). Previous work established three anatomical variants of the sigmoid notch (parallel, oblique, and reverse oblique). The reverse oblique DRUJ poses theoretical risk of increased contact forces following ulnar shortening osteotomy, a common method of treating UAS. Purpose As prevalence of reverse oblique morphology has been under-reported, this study aims to better define the prevalence of reverse oblique morphology in the adult population. Methods Institutional Review Board-approved review of 1,000 radiographs over a 2-year period was performed. Demographic data and radiographic measurements were recorded (ulnar variance, notch inclination, and presence of arthritis). Correlation tests, a test of proportions, a t -test, and linear and logic regression tests were used to examine associations between ulnar variance, sigmoid inclination, sex, age, and presence of arthritis. Results One thousand radiographs were analyzed revealing prevalence rates of: parallel-68%, oblique-26%, and reverse oblique-6%. Females were significantly more likely to have reverse inclination. No significant correlation was noted for morphology by age. Ulna positive variance was negatively correlated with reverse inclination. DRUJ arthritis was noted in 14% of patients. Higher sigmoid inclination was associated with higher odds of presence of arthritis, adjusting for sex and age. Higher incidence of arthritis was noted among patients with the oblique (20.8%) or reverse oblique (24.6%) compared with parallel (10.5%) morphology. Conclusion This series of 1,000 radiographs demonstrates a 6% overall prevalence of reverse obliquity. This large dataset allows for better quantification of the prevalence of DRUJ morphologies and determination of correlations that have clinical implications for patients with ulnar-sided wrist pathology. Level of Evidence This is a Level IV study.

Treatment of Ulnar Impaction Syndrome A Systematic Review

This thesis critically and systematically reviews the surgical treatments for ulnar impaction syndrome. Three types of treatments currently exist: arthroscopic wafer procedure, open wafer procedure, and ulna shortening osteotomy. We aim in this study to systematically review the literature to assess the treatment of the ulnar impaction syndrome which will help in establishing an algorithm for the treatment. By September 2018, we conducted a search on five electronic databases, including PubMed, Scopus, Institute of Science Index (ISI), Google Scholar and Cochrane. We used the following search terms to retrieve the articles that may relate to our topic: (ulnar abutment syndrome, ulnar impaction syndrome) A total of 36 articles were included from searching the electronic databases PubMed MEDLINE, Ovid MEDLINE, and Ovid EMBASE. Studies were evaluated for quality using the Modified Detsky Score. Of these, 14 articles had a Modified Detsky Score of 6/10 or higher. Satisfaction rates were 100% for arthroscopic wafer procedure, 89% for open wafer procedure, and 84% for ulna shortening osteotomy. The percentage of participants reporting an excellent or good outcome was 82% for arthroscopic wafer procedure, 87% for open wafer procedure, and 76% for ulna shortening osteotomy. Available evidence shows that arthroscopic wafer procedure and open wafer procedure may be viable alternatives to the more popular ulna shortening osteotomy, but clinical superiority is yet to be established. Future research should focus on prospective cohort methods and should report participant outcomes using validated scoring methods.

Distal Ulnar Metaphyseal Wedge Osteotomy for Ulnar Abutment Syndrome.

Background Ulnar shortening osteotomy of the diaphysis is a common and effective surgical procedure for ulnar abutment syndrome. However, this procedure has some disadvantages, such as a long period until union and a relatively high nonunion rate. To overcome these disadvantages, we have developed distal ulnar metaphyseal wedge osteotomy. The purpose of this article is to describe the technique and to report its clinical results. Patients and Methods Distal ulnar metaphyseal wedge osteotomy consists of resection of the wedge fragment at the distal ulnar metaphysis, compressing the distal fragment of the ulna toward the radial-proximal direction and fixation with a Herbert type headless screw. We performed this procedure for 58 patients with ulnar abutment syndrome, and the clinical data of 43 patients who were followed for > 6 months were analyzed. We evaluated range of motion, grip strength, and HAND20 which is a validated subjective scoring system in Japan. Results All patients experienced relief from their ulnar wrist pain, and bone union was achieved within an average of 2.6 months. The range of dorsiflexion improved from 63° preoperatively to 69° postoperatively, grip strength compared with the contralateral hand improved from 77% preoperatively to 87% postoperatively, and HAND20 improved from 41.3 points preoperatively to 22.4 points postoperatively. Discussion This procedure has advantages especially in early bone union. This procedure should be taken into consideration as one of the options to treat ulnar abutment syndrome.

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study

To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome. We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n= 14) or diaphyseal (n= 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed. There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group. Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference. Therapeutic IV.

Cigarette Smoking Is Associated With Cubital Tunnel Syndrome

The aim of this study was to validate the potential association between cigarette smoking and cubital tunnel syndrome (CubTS). One hundred patients with CubTS were compared with 100 controls with ulnar abutment syndrome matched for age, gender, and body mass index. The smoking status was compared between patients and controls using the sign test and the Wilcoxon signed rank test. Conditional logistic regression was used to calculate the association between CubTS and pack-years smoked. A significant association was found between increased pack-years smoked and CubTS. A significant difference in the number of never smokers and ever smokers was observed between the patients with CubTS and controls. The difference in mean pack-years in the patients and controls was highly significant. A dose-dependent association with pack-years was found between patients and controls. High cumulative cigarette smoking is associated with CubTS. Muscle Nerve 54: 1136-1138, 2016.

Wrist Injuries in the Immature Athlete

The pediatric skeleton has abundant cartilage and thick periosteum shield that protect the immature athlete. Injuries can still result from excessive overuse or overt high energy trauma. This article will focus on injuries about the pediatric wrist primarily distal radius physeal stress syndrome, ulnar abutment syndrome, scaphoid fractures, and distal radius growth arrest. The diagnosis of these entities along with treatment options will be discussed. Surgical techniques to remedy these difficult problems will be highlighted. Published outcomes after the various surgical procedures will also be reviewed.

Ulnar Abutment Syndrome

With regard to the published article “arthroscopic curettage of intraosseous ganglions of lunate bone” in the last journal edition, it is time to review ulnar abutment syndrome with similar clinical and radiologic findings (1). The main cause of this syndrome is the overload of carpal bones, especially lunate bone related to positive ulnar variance. In normal wrist, 20% of the load is transmitted to ulna whereas 2 mm positive ulnar variance increases this load up to 40%. This problem may even happen in normal wrists because of ulnar variance changes during forearm rotation (2). Other predisposing factors are radial shortening after healed distal radius fractures, scapholunate dissociation, lunatotriquetral dissociation and triangular fibrocartilage complex (TFCC) tears. Most of these patients have pain in ulnar side of wrist associated with dorsoulnar wrist tenderness and positive Nakamura's ulnar stress test (ulnar side wrist pain during flexion and extension of ulnar deviated and pronated and axially loaded wrist). Differential diagnoses are lunate ganglion cysts, vascular grooves and Kienbock’s disease. Routine X-ray and MRI are useful for diagnosis. Radiologic findings are positive ulnar variance associated with lunate sclerosis and sometimes lunate cysts. Pronated grip view may better define ulnar impactions. Diagnostic MRI findings are TFCC degenerative tears and lunate chondromalacia. First line of treatment is nonoperative, including decreasing wrist load and using pain killers. In the absence of good response, operative treatment may be indicated. The most prevalent surgical treatment is ulnar shortening osteotomy to unload lunate bone (3). Alternative option is wafer distal ulna resection (removal of 2 4 mm of distal ulna below TFCC). In Palmers types 2a through 2D, (4) salvage procedures are distal ulna resection in low demand patients (Darrach procedure), Sauve-Kapandji procedure in manual laborers, distal ulnar hemi-resection arthroplasty, and finally ulnar head replacement.

Results of ulnar shortening osteotomy with a new plate compression system

The gold standard for treatment of ulnar impaction has become ulnar shortening osteotomy. Previous reports in the literature have shown not only good results with relief of ulnar-sided wrist pain but also significant nonunion rates and painful hardware necessitating further surgery and potentially, metal removal. The purpose of this paper is to review the success rate of ulnar shortening osteotomy utilizing a low profile compression plate designed specifically for ulnar shortening osteotomy. Ninety-three patients with ulnar abutment syndrome underwent ulnar shortening osteotomy with the low profile osteotomy plate. There were 47 males and 46 females. The Acumed's ulnar shortening system was utilized in all cases. The patients were evaluated for pain, range of motion, grip strength, return to work, time to union, and hardware removal. The patients' results were validated using the Mayo Wrist Score. There was a 100% union rate in the 93 patients. There were no nonunions or delayed unions, or any hardware removal. All patients noted an improvement in their ulnar-sided wrist pain. Utilizing the Mayo wrist classification, the average postoperative score was 84.5. The average preoperative Mayo score was 49.4, for an average increase of 35.1 points. The Acumed's low-contact plate designed specifically for ulnar shortening osteotomy demonstrated 100% union rate and no implant removal in our series. This is the largest study to our knowledge of a series of ulnar shortening osteotomies and successful healing without the removal of any implants. Furthermore, the specifically designed ulnar shortening osteotomy plate significantly simplifies the procedure for the surgeon and improves patient outcomes with relief of ulnar-sided wrist pain.

Revision Wrist Arthroscopy After Failed Primary Arthroscopic Treatment (SS-47)

<h3>Introduction</h3> Arthroscopic treatment of ulnar-sided wrist pain is becoming increasingly prevalent; however, little is known about cases in which primary treatment fails to relieve symptoms. The purpose of this study was to identify common reasons for revision wrist arthroscopy. <h3>Methods</h3> Between March 1997 and July 2010, 23 non-staging revision wrist arthroscopies were performed by the senior author. Twelve patients with intercurrent relief of symptoms or traumatic injury were excluded. One was excluded based on concomitant neuropathy. The remaining eleven patients (5 male and 6 female; mean age 24 years) had symptoms that did not improve with primary arthroscopic treatment, requiring revision wrist arthroscopy at a mean of 14.7 months (4-38 months). Ten patients were originally diagnosed with triangular fibrocartilage complex (TFCC) tears; the remaining patient had no identifiable lesions. Data were collected through retrospective review of intraoperative and clinical findings. <h3>Results</h3> All 11 patients required revision procedures because of persistent wrist pain. In 5 of the 11 patients (45%), distal radial ulnar joint (DRUJ) instability was the major cause for revision. Revisions for all 5 patients revealed TFCC peripheral damage requiring repair (1 revision of an unstable repair, 4 previously treated with only debridement). One patient was lost to follow-up, but all 4 remaining (100%) had complete resolution of pain, regaining normal range of motion (ROM) with DRUJ stability. The chief cause for revision in 5 of the 11 patients (45%) was failure to treat ulnar abutment syndrome (UAS). Initially, 1 of these 5 patients presented with chronic ulnocarpal wrist pain, while 4 of the 5 had presented with pain following injury. These 4 were treated purely as traumatic TFCC tears in prior procedures, with no measures taken to correct ulnar positive variance. Notably, 2 of these patients showed ulnar neutral variance on plain films, but intraoperatively demonstrated lunate cartilaginous damage indicative of dynamic ulnar positive variance. All 5 patients were treated with an arthroscopic wafer ulnar shortening, regaining normal ROM in all cases (100%) and complete relief of pain in 4 (80%). One patient (11%) required revision for a previously undiagnosed scapholunate interosseous ligament (SLIL) tear. This was initially a traumatic case, presenting with ulnocarpal wrist pain that persisted after primary arthroscopic TFCC repair. Revision arthroscopy revealed a Grade-II SLIL tear, which was treated with radiofrequency capsular shrinkage, scaphoid reduction, and percutaneous scaphocapitate pinning. Overall, at an average of 7.3 months follow-up (3-35 months), 10 of 11 wrists (91%) exhibited full ROM, with 8 of the 10 also reporting complete resolution of ulnocarpal wrist pain, as seen in Table 1. <h3>Conclusion</h3> Careful attention to a number of key factors may reduce the incidence of revision arthroscopy. DRUJ instability can be better assessed with arthroscopic-assisted shuck testing, both before and after TFCC repair is performed. A thorough evaluation for UAS—both static and dynamic—in traumatic TFCC tears may reduce the recurrence of pain and revision procedures to address the underlying pathology. Finally, treatment outcomes for traumatic ulnocarpal wrist pain may be improved by identifying concurrent radial-side intercarpal ligament injuries.

Intraosseus synovial cysts of the lunate bone: diagnostic problems

Intraosseous ganglia is one of the most frequent lytic defect at the wrist. Its location in the lunate may be discovered by chance on an X-ray performed for another reason, or because of wrist pain and very rarely for a lunate fracture. A.P., lateral and oblique X-rays are mandatory. Bone scan, CT scan and MRI may be of help. Differential diagnosis may exist with an ulnar abutment syndrome with a lunate defect and with all the lytic bone tumours, a systemic disease or multiple defects as in overuse syndromes. In some cases, there is a condensation around the defect and a Kienböck's disease may be suspected. Thirty-seven patients have been operated on between 1978 and 2001, of which 70% were females. Average age was 34 years (16-58). Clinical presentation was always wrist pain. In seven cases, another carpal localization was present. Surgical treatment consisted in bone curettage and cancellous bone grafting. In four cases, a ganglia emerging from the scapholunate space in soft tissues was combined. Pain disappeared after the procedure. A few patients had a 20-30 degrees wrist flexion decrease but without functional impairment. Several theories have tried to explain the onset of these intraosseous ganglia. In conclusion, these lesions are another cause of wrist pain. One has to be sure that this is this lesion which is the real cause of wrist pain. A systematic X-ray has to be performed for painful soft tissue wrist ganglia.

Ulnar abutment syndrome in a patient with dyschondrosteosis

Ulnar abutment syndrome in a patient with dyschondrosteosis

Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears.

Ulnar shortening osteotomy was performed in 11 wrists with ulnar abutment syndrome, after failed arthroscopic surgery on the TFCC (ten debridements, one repair). A delayed union was present in three, a non-union occurred in two, of whom one needed a revision and grafting procedure. According to the Mayo wrist score, only four had an acceptable outcome. Patient's satisfaction was higher: seven were satisfied, four were not. The postoperative wrist pain score was good in ten patients. Overall outcome was not very successful. Problems related to the procedure could be avoided by adapting the technique (oblique osteotomy, palmar placement of the plate, and compression devices). The key statement remains however to us; ulnar sided wrist pain thought to be caused by an ulnar abutment is not necessarily resolved by decompressing the ulnocarpal joint.